Optimization of conformal avoidance: A comparative study of prone vs. supine interstitial high-dose-rate breast brachytherapy

PURPOSE: Several recent studies indicate high-dose-rate (HDR) breast brachytherapy as an alternative to standard external beam radiation therapy for partial breast irradiation with high dose conformality to the target. However, this article presents an exploration of the possibility of achieving higher conformal avoidance of sensitive structures through detailed and comparative 3D CT-based anatomical dose distribution of a patient in supine and prone positions. METHODS AND MATERIALS: A patient treated with accelerated partial breast HDR breast brachytherapy in the supine position was selected for two CT-based analyses, one in the supine and one in the prone position. The optimized plan (Nucletron HDR planning station) for each position was achieved using graphical optimization with local adjustment of isodose lines to cover the planned target volume (PTV, lumpectomy with 2 cm margin) with 100% of the prescribed dose (34 Gy in 10 fractions) while minimizing the hot spots. Cumulative dose-volume histograms (DVH) were analyzed for the PTV, lung, skin, pectoral muscle, and chest wall. RESULTS: The PTV received 100% of prescribed dose in both the prone and supine positions. A significant (>40%) dose reduction was achieved in the lung in the prone treatment position. Similar dose reductions were also achieved for prone pectoral muscle, chest wall, and breast skin, irradiating less volume with high doses. Pectoral muscle, lumpectomy, and the breast skin showed prominent differences in shape and displacement in the prone compared with the supine position. CONCLUSION: CT-based treatment planning allowed calculations of volumetric dose distribution to the target and all sensitive structures with proper visualization and volumetric delineation of organs of interest. The treatment plan shows significant dose reduction may be possible in various sensitive structures if the patient is treated with HDR brachytherapy in the prone position.